Nokea
A nurse is reviewing the medical records for clients. Which of the following findings should the nurse identify as a risk factor for violent behavior?
- A. Schizoid personality disorder
- B. Alcohol intoxication
- C. Dysthymic disorder
- D. Long-term isolation
Correct Answer: B
Rationale: The correct answer is B: Alcohol intoxication. Alcohol intoxication can impair judgment, lower inhibitions, and increase aggression, leading to a higher risk of violent behavior. Schizoid personality disorder (A) is characterized by social detachment, not necessarily violence. Dysthymic disorder (C) involves chronic low mood but not a direct risk for violent behavior. Long-term isolation (D) may contribute to mental health issues but does not directly indicate violent behavior.
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A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?
- A. Keep a journal of how often you check the locks each night
- B. Snap a rubber band on your wrist when you think about checking the locks
- C. Ask a family member to check the lock for you at night
- D. Focus on abdominal breathing whenever you go to check the locks
Correct Answer: B
Rationale: The correct answer is B: Snap a rubber band on your wrist when you think about checking the locks. This is an effective use of thought stopping technique as it creates a physical distraction and discomfort when the client has obsessive thoughts. It helps interrupt the pattern of behavior and redirects the client's focus away from the compulsion. Keeping a journal (A) may increase anxiety and reinforce the behavior. Asking a family member to check the lock (C) doesn't address the client's need to manage their own thoughts and behaviors. Focusing on abdominal breathing (D) may be a relaxation technique but doesn't directly address the obsessive thoughts.
A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take prescribed antianxiety medication. Which of the following actions should the nurse take?
- A. Inform the client that he does not have the right to refuse medication
- B. Administer the medication to the client via IM injection
- C. Offer the client the medication at the next scheduled dose time
- D. Implement consequences until the client takes the medication
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Implementing consequences until the client takes the medication is the most appropriate action as the client is involuntarily admitted. This approach ensures the client's safety and well-being by addressing the refusal to take prescribed medication. Administering medication via IM injection (B) may escalate the situation and violate the client's rights. Informing the client that he does not have the right to refuse medication (A) is inaccurate and may lead to resistance. Offering the medication at the next scheduled dose time (C) does not address the client's refusal.
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include?
- A. Provide frequent rest periods
- B. Discourage social interaction
- C. Allow unlimited physical activity
- D. Limit the client's choices
Correct Answer: A
Rationale: The correct answer is A: Provide frequent rest periods. During mania, clients with bipolar disorder have high energy levels and may engage in excessive activities, leading to physical and mental exhaustion. Providing frequent rest periods helps to prevent burnout and promotes relaxation. Choice B is incorrect as social interaction can provide support and prevent feelings of isolation. Choice C is incorrect as unlimited physical activity can exacerbate manic symptoms. Choice D is incorrect as limiting choices can cause frustration and may escalate the manic episode.
A nurse in an alcohol treatment facility is caring for a client who states 'my job is so stressful that the only way I can cope is to drink.' The nurse should recognize that the client is displaying which of the following defense mechanisms?
- A. Repression
- B. Rationalization
- C. Introjection
- D. Intellectualization
Correct Answer: B
Rationale: The correct answer is B: Rationalization. Rationalization is a defense mechanism where individuals justify their behaviors or feelings with logical reasoning or excuses. In this case, the client is justifying their drinking by attributing it to the stress of their job. This defense mechanism helps the individual avoid facing the real underlying issues causing their behavior.
Choice A: Repression involves pushing unwanted thoughts or feelings into the unconscious mind, which is not demonstrated by the client's statement.
Choice C: Introjection is the internalization of external beliefs or values, not applicable in this context.
Choice D: Intellectualization is the process of focusing on facts and logic to avoid dealing with emotions, which is not evident in the client's statement.
A nurse is assessing a newly admitted client who has schizophrenia and takes thioridazine. Which of the following findings should the nurse document as an adverse effect of this medication?
- A. Anhedonia
- B. Waxy flexibility
- C. Contractions of the jaw
- D. Incongruent affect
Correct Answer: C
Rationale: The correct answer is C: Contractions of the jaw. Thioridazine is an antipsychotic medication known to cause extrapyramidal side effects such as dystonia, which can manifest as contractions of the jaw. Anhedonia (A) is the inability to experience pleasure, not a side effect of thioridazine. Waxy flexibility (B) is a symptom of catatonia, not a side effect of thioridazine. Incongruent affect (D) refers to a mismatch between expression and emotion, not a side effect of thioridazine.